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Get and Sign Disabled Dependent Form

Get and Sign Disabled Dependent Form

Use a disabled dependent certification 0 template to make your document workflow more streamlined.

On your federal Income tax return? Yes No 6. Is dependent employed? 6a. Date of Hire 6b. Number of hours employed per week. 6c. Describe nature of duties. I certify that the above information is correct and authorize the release of medical information requested with respect to this certification. ________________________________________________ Signature of Subscriber ___________________________ Date Signed TO BE COMPLETED BY ATTENDING PHYSICIAN An unmarried dependent child, who is...
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